Surgical Treatment for Chronic Maxillary Sinusitis - An Overview

Introduction:

Chronic maxillary sinusitis is an infection of the maxillary sinus lasting for more than three months. A sinus is an air-filled cavity lined by mucus that helps to circulate air and fight infection. The head has four pairs of sinuses; they are:

• Maxillary Sinuses- Located in the maxilla (upper jaw), one on either side of the nose, below the eyes.

• Frontal Sinuses- In the forehead, above the eyes.

• Ethmoid Sinuses- Present on either side of the upper nose in the ethmoid bone.

• Sphenoidal Sinuses- Located behind the nose in the sphenoid bone.

All the sinuses mentioned above have openings called ostia, which drain the mucus into the nasal cavity; the maxillary sinus combines with the frontal and the ethmoidal sinuses to form an ostiomeatal complex (OMC). This complex works as a filter and keeps the nose clean and bacterial-free.

An infection can enter the maxillary sinus through the nose or an infected tooth; it triggers an inflammatory reaction resulting in swelling and blockage of the mucosal lining and the ostium. This is known as maxillary sinusitis. The symptoms include:

• Facial pain.

• Dental pain and bad breath.

• Facial tenderness.

• Pus discharge.

• Fever and malaise.

If these symptoms last more than 12 weeks, the condition is considered to be chronic maxillary sinusitis.

Why Do the Symptoms Last So Long?

Ideally, after the onset of the symptoms, the patient consults a physician who prescribes medication (antibiotics, nonsteroidal anti-inflammatories, nasal decongestants, and saline rinses) that provides relief. Unfortunately, there are a few roadblocks to this approach; they are:

• Figuring Out the Source- The first line of action for any sinus infection is to relieve the symptoms; it is assumed that the body will remove the underlying infection with its inbuilt immunity. However, if the infection is caused due to a dental problem, then unless the root cause is addressed, the symptoms will reappear once the patient stops the medication.

• Gravity- Except for the maxillary sinus, the rest of the sinuses discharge the mucus in the downward direction (towards gravity) into the nasal cavity. The maxillary sinus is in the shape of a triangle with an opening at the tip, so for any mucus to drain from the maxillary sinus, it has to travel against gravity in an upward direction. This needs help, especially if the sinus is debilitated due to an infection.

• Immunocompromised- Chronic maxillary sinusitis usually occurs in children whose immune systems have not properly developed and in older people whose immune systems are weakened due to debilitating conditions like diabetes, hypertension, etc. This prone them to recurrent infections, which take time to heal.

Other reasons like seasonal variations and allergies also add to the duration of symptoms.

How Is Chronic Maxillary Sinusitis Treated?

Most cases resolve with medication, but a few patients who do not respond to medical therapy need surgical intervention to remove the infection and drain the fluid. A computed tomographic (CT) scan is taken before the procedure, which helps to check for mucosal thickening, air-fluid levels, ostiomeatal complex obstruction, and fungal calcifications. Then, an otolaryngologist (ENT surgeon) performs the surgery after careful evaluation and may choose any of the below-mentioned options:

• Maxillary Antrostomy With or Without Uncinectomy - This is the standard surgical approach for chronic maxillary sinusitis. After thorough anesthetization, the surgeon places an endoscope (an illuminated medical device) to visualize the maxillary ostium (sinus opening). If the view is obstructed by the uncinate process (a bony projection of the ethmoid), it is removed (uncinectomy) with up-biting (curved) forceps. This provides a clear view of the blocked maxillary ostium, carefully enlarged with cutting forceps. This completes maxillary antrostomy; sometimes, instead of forceps, an inflated balloon can be used to enlarge the ostium; this procedure has certain limitations.

• Caldwell-Luc Procedure - Done intra-orally in patients with fungal infections where complete drainage cannot be achieved due to fungal concretions. After anesthesia, an incision is made over the canine tooth, and the periosteum (tissue over the bone) is elevated. At the canine fossa, the maxillary osteotomy (cutting of the bone) is done using a mallet, osteotome, and rongeurs to create a window into the sinus. The sinus is drained and irrigated, followed by suturing.

• Inferior Antrostomy - It is performed in particular cases. The nasal cavity is sprayed with a decongestant which helps to drain the cavity through the maxillary ostium. At this point, the surgeon can visualize the inferior nasal concha on the side of the nose. These pairs of bones look like a rolled-up scroll and help to humidify the incoming air. Once properly anesthetized, the surgeon punches a hole in this region and creates a window similar to Cladwell-Luc, but instead of the mouth, it is done in the nose.

The sinus is irrigated with saline and packed with gauze soaked in antiseptic. Inferior antrostomy is a relatively outdated technique; it needs to explain the creation of a new window for drainage when there is a natural maxillary sinus opening (ostium) that can be enlarged for the same purpose. It is assumed that it was developed before the invention of the endoscope and is rarely practiced today.

• Functional Endoscopic Sinus Surgery - It is preferred when other sinuses are infected along with maxillary sinuses. It is a minimally-invasive approach with an endoscope to visualize the entire nasal cavity (including the ostiomeatal complex) and inbuilt instruments to enlarge blocked sinus openings and remove any nasal polyps that might obstruct the mucus and airflow. It is done under general anesthesia and can be performed on an outpatient basis; it is the most preferred technique to manage symptoms of chronic sinusitis, with less than ten percent needing revision surgery.

What Happens After the Surgery?

• Once the anesthesia wears off, the patient is checked for extraocular motility (eye movement) and any signs of excessive bleeding.

• If everything seems fine, the patient is discharged with pain medication and instructions for nasal saline irrigation.

• After three to five days, the patient is recalled for a post-operative follow-up, and any crusts or blood clots inside the nasal cavity are removed.

• Initially, weekly, bi-weekly, and quarterly follow-ups are done to monitor healing and recurrence. Post-operative follow-ups play a major role in the success of the surgery.

What Are the Complications of Chronic Maxillary Sinus Surgery?

The following are the possible complications of maxillary antrostomy:

• Optic nerve injury leads to blindness.

• Nasolacrimal duct injury, causing epiphora (excess watering of the eyes).

• Bleeding through the nose is also known as epistaxis.

• Cerebrospinal fluid leak and meningitis (inflammation of layers enveloping the brain).

• Brain abscess.

• Recurrent maxillary sinus infection.

Conclusion

Sinus surgeries are tolerated well, followed by an excellent prognosis. Most patients report a significant improvement in symptoms like headache and nasal obstruction, with only ten percent needing revision surgery. However, any post-operative complications should be addressed immediately, and it is imperative that while managing chronic maxillary sinusitis, a dentist also be part of the interdisciplinary team.